Advance care planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities

Abstract

Background Benefits of advance care planning (ACP) have recently been questioned by experts, but ACP is comprised of discrete activities. Little is known about which, if any, ACP activities are associated with patients’ greater likelihood of receiving value-concordant end-of-life (EoL) care. Objectives To determine which ACP activities [Do-Not-Resuscitate (DNR) order completion, designation of a healthcare proxy (HCP), and/or EoL discussions with physicians], individually and in combination, are associated with the greatest likelihood of receiving value-concordant care, and how results may vary based on patient-reported EoL care priorities. Methods Data from 2 federally-funded, multisite, prospective cohort studies of EoL cancer care from 2002–2019 were analyzed. Cancer patients (N = 278) with metastatic disease refractory to chemotherapy were interviewed for a baseline assessment and followed prospectively until death. Interviews regarding patient priorities occurred a median of 111 days prior to death; data regarding EoL medical care were collected post-mortem from caregiver interviews and medical record abstraction. Patients who 1) prioritized life-extending care, and then received life-extending care (or avoided hospice care), or 2) prioritized comfort-focused care, and then avoided life-extending care (or received hospice care) in the last week of life, were coded as receiving value-concordant care. Results After inverse propensity score weighting, the ACP combination associated with the largest proportion of patients receiving value-concordant care was DNR, HCP, and EoL discussions (87% vs. 64% for no ACP activities; OR = 3.91, p = 0.006). In weighted analyses examining each ACP activity individually, DNR orders were associated with decreased likelihood of life-extending care (89% vs. 75%; p = 0.005) and EoL discussions were associated with increased likelihood of hospice care (77% vs. 55%; p = 0.002) among patients prioritizing comfort. ACP activities were not significantly associated with increased likelihood of receiving value-concordant care among patients prioritizing life-extension. Conclusions and relevance For patients who prioritize comfort, EoL discussions with physicians and completion of DNR orders may improve odds of receiving value-concordant EoL care. For patients who prioritize life-extension, ACP does not appear to improve odds of receiving value-concordant EoL care.

Factors related to advance directives completion among cancer patients: a systematic review

“…In this regard, the results of a systematic review show that the EOL priority was fixed for more than 70% of patients [ 86 ]. Among patients with advanced cancer who prioritized comfort-focused care at the EOL, engaging in an EOL discussion with their physician and completing DNR orders were both significantly related with receiving valuable EOL care [ 87 ].…”

Fearing Pain at the End of Life: A Review of Advance Directives

“…However, prior research has indicated that patients with ADs who specifically requested comfort care were more likely to receive treatments aligned with their wishes compared to those without such directives. 27…”

“…However, prior research has indicated that patients with ADs who specifically requested comfort care were more likely to receive treatments aligned with their wishes compared to those without such directives. 27 These limitations highlight the need for further research to explore a broader range of AD sources and evaluate the actual impact of pain relief provisions and how they directly affect patients, families, and the healthcare team. While earlier studies offer valuable context by emphasizing the significance of ADs in aligning treatments with patients' wishes, they do not directly examine the effectiveness of pain relief provisions.…”

Advance care planning in oncology: a scoping review and some recommendations

“…Thirty-eight studies [15–52] and three reviews were identified [6 ▪ ,8 ▪▪ ,13 ▪▪ ]. Studies were heterogeneous in terms of cancer care contexts, population size and characteristics, research designs, and assessment methods (Table 1).…”

“…Fourteen articles that were not included in these categories are reported in Table 1. They address two topics: ACP uptake rates [39–44]; and ACP outcomes [45–52].…”